Can a patient stop taking hydrocodone (opioid analgesic) suddenly?

Can a Patient Stop Hydrocodone Suddenly?

No, patients should never stop hydrocodone suddenly—abrupt discontinuation of opioids in physically dependent patients can result in serious withdrawal symptoms, uncontrolled pain, suicide, overdose from seeking alternative sources, and death. 1

Why Abrupt Discontinuation is Dangerous

The FDA label for hydrocodone explicitly warns that rapid discontinuation in physically dependent patients has been directly associated with:

• Serious withdrawal symptoms 1
• Uncontrolled pain 1, 2
• Suicide and suicidal ideation 2, 1
• Attempts to find other opioid sources (often illicit substances like heroin), which increases overdose risk 1, 2
• Mental health crisis and emergency department utilization 2

Physical dependence develops after several days to weeks of regular opioid use, and is a normal physiological adaptation—not the same as addiction. 1 When opioids are stopped abruptly, the body's counter-regulatory mechanisms that developed during chronic use suddenly become unopposed, triggering withdrawal. 3

Withdrawal Symptoms to Expect

Common opioid withdrawal symptoms include: 1

• Restlessness, anxiety, irritability
• Lacrimation (tearing), rhinorrhea (runny nose)
• Yawning, perspiration, chills
• Myalgia (muscle aches), backache, joint pain
• Mydriasis (dilated pupils)
• Abdominal cramps, nausea, vomiting, diarrhea
• Insomnia, weakness, anorexia
• Increased blood pressure, respiratory rate, and heart rate

While opioid withdrawal is extremely uncomfortable, it is important to note that benzodiazepine withdrawal carries greater risks than opioid withdrawal (including seizures and death), so if a patient is on both medications, benzodiazepines should be tapered first. 4

Safe Tapering Protocol When Discontinuation is Necessary

The benefits of rapidly tapering or abruptly discontinuing opioids are unlikely to outweigh the substantial risks unless there is a life-threatening issue. 2

Core Tapering Principles:

For patients on long-term opioids, tapers of 10% per month or slower are likely to be better tolerated than more rapid tapers. 2 The FDA label specifies: 1

• Start with small increments: No greater than 10-25% of the total daily dose to avoid withdrawal symptoms 1
• Each new dose should be 90% of the previous dose, not a straight-line reduction from the starting dose 2
• Proceed at intervals of every 2-4 weeks 1
• Longer duration of previous therapy requires a longer taper—tapers can take several months to years depending on dosage 2
• Patients on opioids for briefer periods may tolerate more rapid tapering 1

Critical Monitoring During Tapering:

• If withdrawal symptoms arise, pause the taper or raise the dose back to the previous level, then proceed more slowly 1, 2
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate 2
• Monitor for changes in mood, emergence of suicidal thoughts, or use of other substances 1
• Maximize nonopioid treatments for pain and address behavioral distress before and during the taper 2

Managing Withdrawal Symptoms:

• Withdrawal distress should be preempted and managed with adjuvant medications for specific symptoms such as anxiety and insomnia 2
• Pain itself may be a withdrawal symptom and not simply an exacerbation of original chronic pain 2
• Reassess the patient frequently to manage pain and withdrawal symptoms as they emerge 1

Special Considerations and Common Pitfalls

When Tapering May Not Be Necessary:

Do not insist on opioid tapering or discontinuation when opioid use might be warranted. 2 Tapering is essential only if patients are in serious danger because of medical complications, overdose, or hazardous behaviors. 2

Alternative Approaches:

Consider switching to buprenorphine, especially if the patient has aberrant behaviors or opioid use disorder. 2 Buprenorphine initiation requires discontinuing all opioids the night before, waiting for mild withdrawal, then initiating 2-4 mg repeated at 2-hour intervals until resolution of withdrawal symptoms. 2

Critical Pitfalls to Avoid:

• Never use "cold referrals" to other clinicians who have not agreed to accept the patient during taper 2
• Do not use straight-line tapers that subject patients to increasingly large absolute dose reductions as they approach zero 2
• Do not mandate zero as the target dose for all patients—some may require long-term low-dose maintenance 2
• Do not taper faster than 10% per month for long-term users 2
• Never abandon the patient if tapering is unsuccessful—maintain the therapeutic relationship 2

Post-Discontinuation Risks

Advise patients of increased risk for overdose if they abruptly return to a previously prescribed higher dose because of loss of opioid tolerance. 2, 1 Provide opioid overdose education and offer naloxone. 2

Multimodal Support Required

Ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid taper. 1, 2 This is particularly important for patients treated for long duration and/or with high doses for chronic pain. 1

If discontinuing opioids due to suspected substance use disorder, evaluate and treat the patient, or refer for evaluation and treatment. Treatment should include evidence-based approaches, such as medication-assisted treatment of opioid use disorder. 1